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In this episode of Topical Conversations, Aaron Farberg, MD, joins George Monks, MD, to examine the clinical and logistical realities of transitioning patients from general dermatology to Mohs surgery. Their discussion highlights how evolving treatment options, referral timing, and multidisciplinary coordination influence decision-making, particularly when patients present with complex disease or are already receiving systemic therapy.
The patient journey: from suspicion to surgical planning
The conversation begins with a practical overview of the typical pathway to Mohs surgery. After identifying a suspicious lesion, dermatologists confirm the diagnosis via biopsy and then guide patients through treatment options, including Mohs when appropriate.
A central theme is expectation setting. Patients diagnosed with skin cancer often anticipate rapid surgical intervention; however, real-world scheduling constraints mean wait times of several weeks are common. In many cases of basal cell carcinoma (BCC), a delay of up to approximately 2 months may be clinically acceptable, while higher-risk tumors, such as certain squamous cell carcinomas or melanomas, require more urgent prioritization.
Patients are encouraged to remain engaged during this interval, reporting any changes such as growth, bleeding, or pain. This ongoing communication can help dermatologists reassess urgency and facilitate expedited care when needed.
Managing complexity: when and how to engage Mohs surgeons
For borderline or complex cases, early collaboration with Mohs surgeons is emphasized. Prereferral discussions, which can be supported by clinical images and patient history, can help ensure appropriate patient selection and avoid delays associated with suboptimal referrals.
This bidirectional communication is increasingly important as treatment decisions become more nuanced. In some cases, Mohs surgeons may refer patients back to dermatologists for consideration of systemic therapy prior to surgery, reinforcing the importance of shared decision-making across specialties.
Expanding the toolbox: the role of systemic therapies
The growing availability of systemic therapies, including immunotherapies and targeted agents, has broadened management strategies for advanced or high-risk skin cancers.
Hedgehog inhibitors (HHIs), for example, have become an important option for advanced BCCs that may not be ideal candidates for immediate surgery or radiation. In select cases, systemic therapy may be used in a neoadjuvant approach to reduce tumor burden and improve surgical feasibility.
This approach can also help address practical challenges such as surgical wait times. Initiating systemic therapy during this interval may allow for disease control while optimizing the timing and extent of surgery. However, these decisions require careful coordination and individualized assessment.
Importantly, clinicians note that response to HHIs is often evident within the first 1 to 2 months, which can help guide ongoing management. In patients who respond well, continued therapy may be appropriate, while nonresponders may be redirected toward surgical management.
Addressing clinical uncertainty: skip lesions and treatment timing
The discussion also addresses concerns around “skip lesions,” particularly in the context of preoperative systemic therapy. While discontinuous tumor spread is a theoretical consideration, both clinicians note that it is not commonly observed in their practices and is not a primary deterrent to systemic use.
Greater concern is placed on delays in definitive treatment, which may increase the risk of tumor progression or spread. This reinforces the importance of timely referral and meticulous surgical technique, particularly in cases where tumor margins may be less predictable.
Careful clinical assessment, including thorough inspection and adjunctive tools when appropriate, remains essential in these scenarios.
Looking ahead: integrating new tools with established standards
While Mohs surgery remains a cornerstone of cutaneous oncology, the integration of systemic therapies is reshaping how dermatologists approach complex cases. This discussion highlights the importance of flexibility in treatment planning, balanced with a continued emphasis on evidence-based care and procedural precision.
Above all, consistent and proactive communication remains central to optimizing patient outcomes in this evolving landscape.
Key takeaways